What Can I Expect After Using My EpiPen?

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I recently had skin testing to determine what I was allergic to, and I found out that I was extremely allergic to citrus. Is this common? I now have to carry an EpiPen with me because this allergy closes my throat to the point that I cannot breathe. I had this happen twice before I was tested, and I remembered that both times I was drinking a citrus juice or punch. I just thought I had swallowed wrong and it caused me to get choked up! Now that I'm carrying the EpiPen, I'd like to feel totally prepared. In the event that I have to use it, what should I expect? Are there any symptoms or aftereffects? Does it completely stop the allergic reaction?

— Gretchen, Arizona

Citrus is not a terribly common allergy, to answer your first question, although I have seen it before. More important, it is not one that must be listed, by law, on the ingredients list of a commercially prepared food. So citrus in a food could be listed as a "flavoring," "seasoning," or "natural flavoring" and is something you should watch out for if you know it's a trigger.

I'm glad you were able to get tested and identify the cause of your attacks. That is half the battle, and knowing what the trigger is makes it far more likely that you will be able to avoid it successfully in the future. However, you should always be prepared for an accidental exposure, especially when you're eating food that you didn't prepare yourself. High-risk occasions at which you may accidentally ingest trigger foods include special events (like family reunions, weddings, parties), during which you may not be paying as close attention to the food; buffets or banquets; and travel, when you may be eating out for every meal. Always have your EpiPen with you so that it becomes second nature and you don't take risks. Even people who know their triggers and are smart and careful about avoiding specific foods have unexpected attacks, simply because of the way we eat today. Commercial foods have so many ingredients that aren't necessarily obvious, and so much of our food is prepared by others, that it's very difficult to avoid something completely.

The answer to your next question — what should you expect to feel when you give yourself a shot of epinephrine? — is somewhat dependent on you as well as on the attack itself. I have had people tell me that the epinephrine brought nothing but instant relief from the symptoms, and that they didn't really feel any side effects. On the other hand, when I give epinephrine in the office (usually because of an allergic reaction to allergy shots), people most often feel very cold and jittery for a half hour or so afterward. As is true of all medications, people's responses vary. In general, though, I think the most common side effects are feeling cold and shaky or jittery, and perhaps feeling your heart race a bit. The side effects, if they occur, are actually very similar to how you feel after a bad fright. I tell people that they may feel similar to the way they'd feel after almost having a car accident. People in that situation often pull off the road to collect themselves and calm down. Such feelings are produced by adrenaline, and because epinephrine is just manufactured adrenaline, it can make you feel essentially the same.

I think the severity of the allergic reaction may also influence how people react to the epinephrine — that is, when people have a severe allergic reaction, the epinephrine seems to have fewer side effects and all that people recall is the relief. If the reaction is mild, the epinephrine may seem to them to be stronger and to have more side effects. This is just my impression from talking to people; it is certainly not backed up by any studies.

Finally, to address the last of your questions — does epinephrine completely stop the allergic reaction? — it usually does, but not in all cases. That is why many allergists ask people to carry two pens with them at all times. If the first dose does not seem to clear up symptoms completely, a second dose can be given a few minutes later, though exactly when to give that dose is also dependent on the individual. Often the person can feel when a reaction is gradually decreasing, in which case a second dose becomes unnecessary. People with anaphylaxis are told to go to the nearest emergency room after using their epinephrine for this reason — in case they need a second or third dose. Very large or overweight people may more often require a second dose than others. I hope this helps you understand better what to expect.

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